Anesth Pain Med 2019;14:441-448 https://doi.org/10.17085/apm.2019.14.4.441 pISSN 1975-5171ㆍeISSN 2383-7977 Clinical Research Current use of neuromuscular blocking agents and antagonists in Korea: a 2018 survey Jin Sun Kim1, Jung Woo Han1, Jae Ho Lee1, Jae Moon Choi2, Ha Jung Kim2, Tae-Yun Sung3, Yong Beom Kim4, Yong Seop Shin5, and Hong Seuk Yang6 Received November 19, 2018 Revised 1st, January 28, 2019 2nd, February 28, 2019 3rd, March 26, 2019 4th, May 14, 2019 Accepted May 14, 2019 Department of Anesthesiology and Pain Medicine, 1Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, 2Asan Medical Center, University of Ulsan College of Medicine, Seoul, 3Konyang University Hopsital, Konyang University College of Medicine, Daejeon, 4Gil Medical Center, Gachon University College of Medicine, Incheon, 5Chungnam National University Hospital, Chungnam National University College of Medicine, 6Daejeon Sun General Hospital, Daejeon, Korea Methods: Anesthesiologists working in Korea were invited to participate in an online survey via email January 2–February 28, 2018. The questionnaire consisted of 45 items, including preferred NMBAs, antagonists, neuromuscular monitoring, and complications related to the use sugammadex. A total of 174 responses were analyzed. Corresponding author Hong Seuk Yang, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Daejeon Sun General Hospital, 29 Mokjung-ro, Jung-gu, Daejeon 34811, Korea Tel: 82-42-220-8921 Fax: 82-42-220-8933 E-mail: hsyang@amc.seoul.kr ORCID https://orcid.org/0000-0003-2023-8705 Results: Rocuronium was a commonly used NMBA for endotracheal intubation (98%) of hospitals, and maintenance of anesthesia (83.3%) in of hospitals. Sugammadex, pyridostigmine, and neostigmine were used in 89.1%, 87.9%, and 45.4% of hospitals. Neuromuscular monitoring was employed in 79.3% of hospitals; however only 39.7% of hospitals used neuromuscular monitoring before antagonist administration. Usual dosage range of sugammadex was 2.1–4 mg/kg in 35.1% of hospitals, within 2 mg/kg in 34.5% of hospitals, and 1 vial regardless of body weight in 22.4% of hospitals. Sugammadexrelated complications were encountered by 14.9% of respondents. Conclusions: This survey indicates several minor problems associated with the use of antagonists and neuromuscular monitoring. However, most anesthesiologists appear to have appropriate information regarding the usage of NMBAs and sugammadex. Keywords: Neostigmine; Neuromuscular blocking agents; Neuromuscular monitoring; Pyridostigmine bromide; Sugammadex. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright ⓒ the Korean Society of Anesthesiologists, 2019 441 KNRS Background: Neuromuscular blocking agents (NMBAs) and neuromuscular monitoring in anesthetic management are integral for endotracheal intubation, better visualization of the surgical field, and prevention of residual neuromuscular blockade and pulmonary complications. Sugammadex is a drug that reduces risk of residual neuromuscular blockade, with more rapid recovery compared to anticholinesterase. The purpose of this study was to investigate current usage status of NMBAs and antagonist with neuromuscular monitoring, among anesthesiologists in Korea. Anesth Pain Med Vol. 14 No. 4 INTRODUCTION or three responses in order of preference, depending on the type of question; the assessment was made based on the During anesthetic management, neuromuscular blocking popular responses. In some instances, the total number of agents (NMBAs) can enhance ease of endotracheal intuba- responses could exceed 174, due to duplicate responses, so tion, field of view, and operating conditions while reducing the sum of responses was computed with the sum of dupli- the dose of inhalation or intravenous anesthetic agents and cate responses and presented as percentage of total number. are also essential for respiratory management for intraopera- The survey consisted of 45 items, including demographic tive controlled mechanical ventilation [1,2]. Furthermore, information such as length of career at the hospital, features neuromuscular monitoring and antagonist administration of the hospital, and area of residence, as well as information are important for preventing complications of residual neu- about application of NMBAs and neuromuscular monitoring romuscular blockade, such as dyspnea, hypoxia, atelectasis, devices, preference for NMBA antagonists, current use of su- and pneumonia [3]. Particularly, neuromuscular monitoring gammadex, and its complications. provides important information for neuromuscular dose ad- RESULTS justment, neuromuscular action for endotracheal intubation, timing of antagonist administration postoperatively, and determination of its dose. The use of antagonists during recovery for patients who received NMBAs restores spontaneous Table 1 shows the details of anesthesiologists who participated in the survey. breathing and prevents residual neuromuscular blockade Rocuronium was the most popular agent for endotracheal and recurarization by adequately recovering muscle strength intubation and intraoperative maintenance of neuromus- (train-of-four ratio [TOFr] > 0.9) [4,5]. cular blockade (Table 2). Regarding neuromuscular reversal Sugammadex is an antagonist of the aminosteroid non- agents available at each hospital, sugammadex was the most depolarizing neuromuscular blockers vecuronium and ro- common (89.1%), followed by pyridostigmine (87.9%). When curonium; compared to anticholinesterases, it is an effective asked to choose three neuromuscular block reversal agents drug that promotes and quick recovery while lowering the in the order of frequent use, 142 out of 174 (80.2%; 177 cases risk of residual neuromuscular blockade [6]. In Korea, it has including duplicate responses) chose anticholinesterases been introduced in 2013. Thus, it was considered possible (pyridostigmine, n = 96 [54.2%], neostigmine n = 46 [26.0%]) that there might have been changes in the use of NMBAs and as the most preferred agent, while 35 (19.8%) chose sugam- antagonists in clinical practice. madex as their primary choice. On the other hand, 101 out We hereby report a survey of the selection of NMBAs for of 160 (63.1%) chose sugammadex as the second-most pre- endotracheal intubation and anesthesia maintenance, the ferred antagonist, while 39 (24.4%) chose pyridostigmine and usage of neuromuscular monitoring and choice of antago- 20 (12.5%) chose neostigmine. The most popular combina- nists well as anesthesiologists’ update concepts in Korea. tion of anticholinergics used with anticholinesterases was pyridostigmine + glycopyrrolate, followed by neostigmine + MATERIALS AND METHODS glycopyrrolate and neostigmine + atropine. The reasons for not using antagonists were “because NMBAs are not used at An anonymous questionnaire was administered to anes- all” (30.5%), “because patient seemed adequately recovered thesia specialists and residents in clinical practice who are or an adequate amount of time has passed” (26.4%), and registered members of the Korean Society of Anesthesiolo- “complete recovery was confirmed using monitoring devices gists (KSA) and who live in Korea. The survey was sent via such as TOF” (13.8%); 22.4% of participants stated that they email for the anesthesiologists to complete the online survey always used neuromuscular block reversal agents. themselves; 174 responses that were delivered via the web Approximately 93.1% of the participants stated that they link (https://goo.gl/forms/cNLvOyoftVJjWfKS2) within two were aware of the cost of sugammadex. Regarding the use of months from January 2 to February 28, 2018 were analyzed. sugammadex, it was used for all patients of general anesthe- Participants were instructed to give either a single response 442 sia by 9.8% of the respondents, only used for recommended www.anesth-pain-med.org Current use of NM blockers and antagonists Table 1. Demographic Data Question Question 38 (21.8) 136 (78.2) 135 (77.6) 39 (22.4) 46 (26.4) 45 (25.9) 49 (28.2) 34 (19.5) 7 (4.0) 10 (5.8) 157 (90.2) 83 (47.7) 69 (39.7) 18 (10.3) 4 (2.3) 25 (14.4) 13 (7.5) 8 (4.6) 67 (38.5) 34 (19.5) 11 (6.3) 16 (9.2) 70 (40.2) 32 (18.4) 14 (8.0) 10 (5.7) 8 (4.6) each 7 (4.0) each 1 (0.6) 6 (3.4) each 5 (2.9) 0 (0) Values are presented as number (%). Choose NMBAs that are mainly used for endotracheal intubation (multiple selection is possible) Succinylcholine Rocuronium Vecuronium Atracurium Cisatracurium Choose NMBA that is mainly used for maintenance of anesthesia Succinylcholine Rocuronium Vecuronium Atracurium Cisatracurium Choosereversal agents of neuromuscular blockade that were prepared in your hospital (multiple selection is possible) Neostigmine Pyridostigmine Edrophonium Sugammadex If you do not use the reversal agents during recovery from anesthesia, why is that? Because of not use of any NMBAs at all Because sufficient time has passed since the administration of the NMBA Because the symptoms of the patient are fully recovered Since complete recovery was confirmed using neuromuscular monitoring device such as TOF I always use the reversal agent Others Result 17 (9.8) 167 (96.0) 14 (8.0) 2 (1.1) 44 (25.3) 0 (0) 145 (83.3) 15 (8.6) 1 (0.6) 13 (7.5) 79 (45.4) 153 (87.9) 0 (0) 155 (89.1) 53 (30.5) 23 (13.2) 23 (13.2) 24 (13.8) 39 (22.4) 12 (6.9) Values are presented as number (%). NMBA: neuromuscular blocking agent, TOF: train-of-four. they administer one vial (200 mg), regardless of the patient’s weight or condition (Table 3). A total of 79.3% of the participants said that their hospital was equipped with devices for monitoring neuromuscular function. Approximately 39.7% said that the monitoring de- indications by 40.2%, occasionally or rarely used by 36.2%, vice was used prior to administering antagonists, while 60.3% and never used by 9.2%. The reasons for the restrictions in said that it was not. When determining the timing of antago- clinical usage included regulations such as diagnosis-related nist administration, most participants used TOF stimulation group (50.0%), price (31.1%), and limited indications (10.9%). results, while 1.2% said that they administer antagonists once Regarding the degree of restriction of sugammadex usage, surgery is concluded, regardless of the results of neuromus- 89.1% of the participants stated that they “use it without re- cular monitoring (Table 4). strictions” or “use only for a small minority of patients,” sug- Approximately 14.9% encountered adverse reactions after gesting that the majority of them are using it in clinical prac- sugammadex administration. Types of adverse reactions tice. Regarding the dosage of sugammadex, 22.4% said that included decreased systolic blood pressure below 80 mmHg, www.anesth-pain-med.org 443 KNRS Position Resident trainees Board-certified anesthesiologists Affiliation University hospital Nonteaching hospital Years of working in anesthesiology department <5 5–10 11–20 > 20 Size of hospital < 50 beds 50–100 beds > 100 beds Number of daily average general anesthesia which is performed by respondent <5 5–10 10–20 > 20 Number of daily average general anesthesia which is performed in respondent’s hospital <5 5–10 10–20 21–50 51–100 100–200 > 200 The practice location of respondents Seoul Gyeonggi-do Busan Incheon Daejeon, Gangwon-do Daegu, Gwangju Ulsan Chungcheong-do, Jeolla-do Gyungsang-do Jeju-do Result Table 2. Availability and Usage Status of Neuromuscular Blocking and Reversal Agents Anesth Pain Med Vol. 14 No. 4 Table 3. Availability and Usage Status of Sugammadex Question Result Do you know the amount of money you need to use sugammadex? Yes 162 (93.1) No 12 (6.9) How often do you use sugammadex as an antagonist of neuromuscular blockade? In all patients 17 (9.8) Use only in recommended indications 70 (40.2) I use it occasionally 53 (30.5) It is rarely used 10 (5.7) I do not use it at all 16 (9.2) Others 8 (4.6) Do you have limited use of sugammadex, select a reason Due to (expensive) price 54 (31.1) Due to regulations such as DRG, car insurance 87 (50.0) Due to restricted indication 19 (10.9) Due to sugammadex-related side effects 2 (1.1) Others 12 (6.9) If you have restrictions on using sugammadex, select a level of restriction None restriction 29 (16.7) There are some limitations, but they are freely usable 82 (47.1) Partially restricted 29 (16.7) Used only in very few patients who have indications 15 (8.6) Completely restricted 12 (6.9) Others 7 (4.0) If sugammadex is administered to antagonize the neuromuscular blockade, select a routine dosage ≤ 2 mg/kg 60 (34.5) 2.1–3.9 mg/kg 42 (24.1) 4 mg/kg 19 (10.9) 8 mg/kg 1 (0.6) 16 mg/kg 0 (0) One vial regardless the body weight 39 (22.4) Others 13 (7.5) Have you experienced any complications due to sugammadex? Yes 26 (14.9) No 148 (85.1) Values are presented as number (%). DRG: diagnosis-related group. Table 4. Application Status of Neuromuscular Function Monitoring Device Question Result Does your hospital have monitoring device of neuromuscular function? Yes 138 (79.3) No 36 (20.7) Do you measure neuromuscular function recovery before administration of reversal agents? Yes 69 (39.7) No 105 (60.3) How often do you monitor neuromuscular function in your patients receiving NMBAs? In all patients 15 (8.6) In 75% of patients 19 (10.9) In 50% of patients 10 (5.7) In 25% of patients 56 (32.2) Only in patients with abnormal neuromuscular 27 (15.5) function (e.g., myasthenia gravis) Only for a limited number of studies 9 (5.2) Never 33 (19.0) Others 5 (2.9) If the neuromuscular monitoring is performed during surgery, select when to administer the reversal agents to reversal of the neuromuscular blockade Posttetanic count ≤ 5 0 (0) Posttetanic count 6–10 0 (0) TOF count 1 7 (4.0) TOF count 2 36 (20.7) TOF count 3 30 (17.2) TOF count 4 39 (22.4) TOF ratio ≤ 0.5 7 (4.0) TOF ratio ≥ 0.5 19 (10.9) TOF ratio ≥ 0.9 9 (5.2) Others 27 (15.5) Values are presented as number (%). NMBA: neuromuscular blocking agent, TOF: train-of-four. NMBA and recurarization. Countermeasures included oxygen administration, additional administration of sugammadex, endotracheal intubation, placement of ventilator, administration of opioid antagonist and application of continuous anaphylaxis, and increased intra-tracheal pressure (e.g., positive pressure ventilation, administration of vasopressors, due to bronchospasm) requiring endotracheal intubation and treatment equivalent to cardiopulmonary resuscitation. and mechanical ventilation, and reduced oxygen saturation: other adverse reactions included bradycardia, cardiac ar- DISCUSSION rest, reduced vigor, perspiration, postoperative delirium, and headache. If hypoxia or dyspnea occurred after sugammadex Anesthetic management has undergone substantial chang- administration, the most common causes were thought to es with the introduction of novel pharmacologic agents such be insufficient dose of antagonist, residual effect of narcotic as NMBAs. The present survey aimed to investigate changes analgesics, residual effects of anesthetics, residual effects of of anesthesiologists’ perceptions and current use of NMBAs 444 www.anesth-pain-med.org Current use of NM blockers and antagonists and antagonists, and the application of neuromuscular mon- lapsibility and risk of postoperative atelectasis after reversal itoring since the introduction of sugammadex; a total of 174 of neuromuscular blockade, subsequent studies concluded participants completed the survey. A considerable percent- that using an appropriate dose of anticholinesterase under age of anesthesia specialists who participated in the survey neuromuscular monitoring was helpful in preventing post- (over 40%) worked in large hospitals in Seoul and Gyeonggi operative respiratory complications related to NMBAs [15]. regions, and in other large cities, which was borne out by the If an additional administration is needed because the initial proportion of their responses [7]. A total of 136 out of 4,521 dose of anticholinesterase did not induce complete reversal, anesthesia specialists (3,946 excluding those on leave; 3.4%) the authors recommend that they must be used with cau- and 38 out of 815 anesthesiology residents nationwide partic- tion, and sugammadex is recommended [6,16]. With the ipated in the survey, so the present survey has an established introduction of sugammadex, the formation of rocuronium- significance. sugammadex complex has enabled predictable and prompt reversal of neuromuscular blockade regardless of the depth and short duration of action that enables fast recovery with of blockade, which has not been possible with other NMBA- low or non-organ dependence, and no other toxicity effects, antagonist combinations, and as a result, catch phrases such must not be accumulated in the body, have no side effects as “So Long, Sux!” and “So Long, Neostigmine!” were intro- such as cardiac arrhythmia or histamine release, and be easy duced [4]. Currently, determining the accurate dose and tim- to reverse [8,9]. There is currently no such NMBA available, ing of sugammadex with neuromuscular monitoring, and, if and among NMBAs that are currently used in clinical prac- an emergency reoperation is needed for patients who were tice, rocuronium and cisatracurium would be the closest to administered sugammadex, determining the accurate dose an ideal NMBA among aminosteroids and benzylisoquino- and timing of rocuronium has become more important as liniums, respectively. Particularly, rocuronium has gained opposed to selecting an anticholinesterase [17,18]. In addi- preference before the introduction sugammadex that enables tion, if neuromuscular blockade is required for reoperation fast and predictable recovery [10]. In the present survey, only but cannot be achieved with rocuronium and sugammadex, a handful of anesthesiologists (9.8%) chose succinylcholine benzylisoquinoliniums (e.g., cisatracurium) or succinylcho- as the NMBA for endotracheal intubation, while 96.0% chose line could probably be used [6,19,20]. If cisatracurium is used, rocuronium. This contrasts to the results of a 2010 survey of rocuronium that did not bind to sugammadex and nicotinic Korean anesthesiologists, in which 73.1% chose succinylcho- acetylcholine receptors that did not bind neuromuscular line for endotracheal intubation [11]. This trend seems to be blockers could induce priming effects, thereby causing an attributable to the fact that anesthesiologists prefer agents earlier onset of action for cisatracurium [21]. with a fast onset and easy reversal of rocuronium and vecuronium, such as sugammadex. Anticholinergics used with anticholinesterases include atropine and glycopyrrolate. In clinical practice, glycopyr- Among anticholinesterases, edrophonium cannot be used rolate is generally preferred to atropine despite its lower due to its unavailability in Korea, while neostigmine and antimuscarinic effects, which was reflected in the present pyridostigmine are available for use. The less frequent use survey. Takkunen et al. [22] reported that the combination of of neostigmine compared to pyridostigmine seems to be neostigmine and glycopyrrolate has less effects on the central attributable to a past trend. Compared to pyridostigmine, nervous system with greater protective effects against oral neostigmine has a faster onset but shorter duration, has a secretions, such as saliva, and promotes cardiac stability due five-fold higher potency, and greater muscarinic action, to a low risk of bradycardia and junctional arrhythmias com- although there are no differences in recovery with neuro- pared to the combination of neostigmine and atropine dur- muscular blockade [12,13]. Hence, if an anticholinesterase ing the reversal of neuromuscular blockade by pancuronium, must be used, neostigmine, which is high potency and has a but there is no difference in the incidence of postoperative fast onset of action, is preferentially recommended [13,14]. nausea and vomiting [13,23]. Although there has been a report suggesting that anticho- In rare cases, antagonists are not used during recovery linesterase administration increases upper respiratory col- after the use of NMBAs. In the present survey, only 22.4% of www.anesth-pain-med.org 445 KNRS An ideal NMBA is a non-depolarizing agent with fast onset Anesth Pain Med Vol. 14 No. 4 the respondents said that they always use an antagonist, and administering antagonists after T2 or higher was detectable. the rates of routine use of antagonists in Europe and United However, some anesthesiologists administered antagonists States are only 18% and 34%, respectively [14]. However, it after surgery was completed, regardless of the results of neu- is impossible to qualitatively and quantitatively examine the romuscular monitoring. Regarding the dose of sugammadex, residual effects of NMBAs without using antagonists, thereby most participants reported using one vial or less, presum- increasing the risk of residual neuromuscular blockade or ably due to the high cost of the agent. Although many studies recurarization [24]. Therefore, a neuromuscular monitoring recommend administering 2.0 mg/kg of sugammadex when device should be used for all patients who are administered T2 is detectable, the dosage may be adjusted based on the NMBAs, and the use of antagonists (and if used, the type and PTC or TOF ratio. The authors suspect that if sugammadex is dose of the agent) should be decided with reference to the administered after T2 is detected, administering 1 vial of su- monitoring results [24,25]. gammadex without neuromuscular monitoring, based only The most important factors for addressing the problems on body weight, may lead to an unnecessary excessive dose, after neuromuscular blockade, such as residual neuromus- but anesthesiologists should take precaution as insufficient cular block, recurarization, and consequent pulmonary com- dosage in obese patients may induce residual neuromuscular plications, are monitoring of neuromuscular functions and blockade or re-blockade [27]. administration of appropriate antagonists [26]. In the present Regarding adverse reactions with sugammadex adminis- survey, 79.3% reported that a neuromuscular monitoring tration, we only listed the type of reactions because duplicate device was available for clinical application at their hospi- responses could alter the actual frequency. The causes of tal, which was similar to the rates reported in a 2010 Korean adverse reactions included residual effects of NBMAs, recu- survey (available in operating room [OR]: 83.3%, available rarization, insufficient dose of sugammadex, and hypersensi- in hospital: 79.5%) [11]. Methods such as TOF are used at a tivity, but some participants mentioned the residual effects of frequency of 22.7% in the United States and 70.2% in Europe, the main anesthetic and opioid. Countermeasures included and the percentage of hospitals equipped with a neuro- oxygen administration, additional sugammadex administra- muscular monitoring device in an OR is 71.4% in the United tion, pressor agents, endotracheal intubation and ventilation, States and 44.5% in Europe [14]. Furthermore, the percentage and CPR, and anesthesiologists seem to have performed ap- of participants who do not use neuromuscular monitoring at propriate therapeutic interventions according to the severity all was 9.4% in the United States and 19.3% in Europe [14]. In of the adverse reactions. However, residual neuromuscular Korea, the clinical application of sugammadex seems to have blockade and recurarization may occur after sugammadex been influenced by insurance coverage, financial burden due administration, and insufficient dosage, hypersensitivity, and to costly drug price, diagnosis-related group (DRG), and indi- anticoagulation can also occur. Moreover, we must think cations designated by the Ministry of Food and Drug Safety. about measures to address problems regarding interactions Furthermore, only 25.3% said that they apply neuromuscular between sugammadex and drugs that may affect its binding monitoring for more than 50% of all surgical patients. These affinity, as well as patients’ condition and other abnormali- results indicate that there have been no changes in the clini- ties [27]. To resolve or prevent these problems, an accurate cal application of NMBAs over the last decade, calling for the understanding of the timing and dosage of sugammadex is KSA and Korean Neuromuscular Research Society (KNRS) needed in addition to neuromuscular monitoring [28]. Re- to develop, promote, and provide education with relevant sidual neuromuscular block after sugammadex administra- guidelines. tion occurs as a result of non-routine use of neuromuscular Regarding the determination of the timing of antagonist monitoring, low usage of monitoring results, lack of standard administration, none of the participants chose tetanic stimu- for neuromuscular monitoring, lack of accurate data about lation and post-tetanic counts (PTC); most participants re- prevalence and mortality of adverse reactions, and high costs. ported using TOF to determine the timing of reversal admin- Furthermore, although hypersensitivity cannot be predicted, istration for performing neuromuscular monitoring. More most cases occur within five minutes of administration, so than 90% of the participants used TOF, and they reported changes in the patient’s state immediately after administra- 446 www.anesth-pain-med.org Current use of NM blockers and antagonists ORCID tion should be carefully observed. In general, bradycardia can occur proportionally to the dose, so treatment using appropriate drugs in addition to accurate neuromuscular moni- Jin Sun Kim: https://orcid.org/0000-0002-3753-2997 toring and dosage are crucial [29]. Jung Woo Han: https://orcid.org/0000-0002-3337-010X One limitation of this study is the possibility of bias, as the Jae Ho Lee: https://orcid.org/0000-0002-2965-5794 sample size was 174, which is less than 5% of the total num- Jae Moon Choi: https://orcid.org/0000-0002-1161-6586 ber of registered anesthesiology specialists and residents Ha Jung Kim: https://orcid.org/0000-0002-1759-4592 currently working in Korea (as of 2018). Despite the small Tae-Yun Sung: https://orcid.org/0000-0002-0714-1477 sample size and the fact that some participants work at the Yong Beom Kim: https://orcid.org/0000-0003-2369-6525 same hospital and thus their responses may be redundant, Yong Seop Shin: https://orcid.org/0000-0001-5071-734X the study population varied in terms of job position, length of career, type of hospital, and region of work, so the findings REFERENCES would be helpful in understanding the current use of NMBAs, neuromuscular monitoring, and antagonists. Second, in the 1. Madsen MV, Staehr-Rye AK, Claudius C, Gätke MR. Is deep neu- survey about the adverse reactions of sugammadex, the ques- romuscular blockade beneficial in laparoscopic surgery? Yes, tionnaire was designed such that online submission was only probably. Acta Anaesthesiol Scand 2016; 60: 710-6. possible after choosing a response even if some items were redundant or were not applicable. In such cases, we only list- 2. Meakin GH. 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